Project Summary/Abstract A prostate biopsy is the most common procedure to evaluate an elevated prostate specific antigen (PSA) or abnormal prostate exam during prostate cancer screening. The biopsy is typically performed with a rectal ultrasound in order to guide needle biopsies into designated areas of the prostate. The office-based procedure is relatively safe and is one of the most common urologic procedures performed in industrialized countries. However, the most common class of antibiotics used to protect from infection (fluoroquinolone) has become less effective due to resistance, despite it being the standard of care. A particular strain of bacteria named E. coli ST131 causes the majority of infections due to it nearly inherent resistance to fluoroquinolones. In this study, we randomize men to antibiotic augmentation by physician?s discretion (in addition to a fluoroquinolone if they chose) versus a rapid test to identify the ST131 E. coli using polymerase chain reaction (PCR) at the time of biopsy. If identified, we would advise the use of an additional antibiotic based on previous studies that have identified antibiotics that typically are less resistant for that particular type of bacteria. We feel this would reduce the current strategy of either augmenting all patients with more broad-spectrum antibiotics or using ill- defined risk based strategy. The more targeted use of antibiotics could help preserve broad-spectrum antibiotics and reduce future antibiotic resistance. A similar strategy has been described using rectal culture prior to prostate biopsy; however, this technique has not been popularized in part due to logistical issues and physician-patient inconvenience. We project that a rapid point of care test may be more easily implemented across various practices and encourage more targeted use of antibiotics, while also reducing infections of the prostate biopsy. Secondary aims of the study are to investigate the clinic workflow and perceptions of clinicians and patients regarding the new technology. Previous attempts to guide prophylaxis have failed due to implementation; therefore, our study will allow us to gain insight into how best to address antibiotic choices that will have the best chance of success urologic practice.